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Course in The Ward

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1K views

Course in The Ward

Uploaded by

enzomarfal
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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VI.

Course in the Ward:

February 25, 2011

 Patient was admitted under the service of Dr. Cagayan


 IVF: D5LR 1 liter x 80
 NPO
 Diagnosis: +/c ectopic pregnancy 5 – 6 weeks, R/O acute appendicitis
 For transvaginal ultrasound STAT – ®
 Request for U/A with pregnancy test and CBC with BT STAT
 Admitting physician and OBROD informed
 Refer for surgery (for futher evaluation and management)
Dx: R/O acute appendicitis

 Rounds w/ Dr. Dizon


 Lab result noted
 UTZ request
 Stand by exlap
 To OR for E exlap at 4:30 pm
 4 pm patient was brought to the ER
 Vital Sign monitoring every 1 hour
 Hook D5W 500 cc + 4 ampule of Isoxilan (Duvadilan) to run at 12mgtts/min, as side drip
 IVF: D5LR 1 liter x 8°

 Given Ampicillin 1gm TIV (-) ANST


 Nubain 5mg + Phenergan 25mg TIV
 Plasil ½ ampule TIV + Raniticline ½ ampule TIV

7:55 PM
 To OR, Status Post EL, Salphingoooferectomy, ® w/ SAB – CLEA
 Oxygen at 3 – 4 LPM via nasal cannula
 Vital sign monitoring very 15 minutes until patient is stable and record
 Temporarily NPO, clear liquid at 2 am and general liquid tomorrow (Feb. 26)
 IVF: D5LR 1 liter x 8° x 3 cycles
 Side Drip: Duvadilan Drip x 12 mgtts/min
 Medicines:
> Ampicillin 1gm IV (-) ANST (-) LD then 500 mg IV q 6°
> Paracetamol 300 mg q 4° x 4 doses
> Morphine SO4 0.02% 10 cc / E C q 12°, 1st dose given at 8 pm
> Defe
> Duphaston 1 tablet PO TID x 1 week to start tomorrow (Feb 26)
> Idenet w/ Follic Acid 1 tablet PO q 4° to start tomorrow (Feb 26)
 Monitor Urine Output every 1 hour, refer if urine output < 30cc/nn every 2 consecutive hours
 Abdominal binder placed
Date Problem / Focus Management Evaluation / Patient’s Nursing
(Medical or Nursing Response Responsibilities
Management)

February 26, 2011


6 : 50 AM Post – operative care - Patient may have - Patient’s needs - Keep the client
small liquid diet were attended rested and
- Soft diet should comfortable
be provided if - Encourange
the client has client to increase
flatus already oral fluid intake
- DAT if client has - Encourange
(+) BM client to comply
with the strict
- S/D to follow: diet ordered.
D5W 500 cc + 4
ampule
amoxicillin

4 : 30 pm For continuity of care - May have DAT - Patient’s needs - Patient advise
for dinner. were attended complete bed
- IVF is to rest without bath
consume and room privileges
discontinue.

Oral meds:
- Duphaston 1 tab.
x 1 week
- Iberet with Follic
Acid 1 tab PO
BID
- Paracetamol
500mg PO q 4°
- Start:
Isoxsoprine 10
mg tab then TID
- Start:
Amoxicillin 500
mg PO q 8° x 7
days
- Hold morphine
sulphate at the
moment.

February 27, 2011


10 : 00 AM - For continuity - Continue DAT - Patient’s needs - Encourage client
of care - Epidural catheter were attended to sit on the bed.
w/ blue drip
were removed.

Oral Meds:
- Amoxicillin
500mg PO every
8 AM x 7 days
- Duphaston 1 tab
TID PO x 1
week
- Paracetamol
500mg PO q 4°
- Iberet + Follic
Acid 1 tab PO
BID

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